CILNCP is a member of the Pennsylvania Council on Independent Living (PCIL). A consumer controlled state association of Centers for Independent Living.
Center for Independent Living of North Central PA (CILNCP) Child with a disabilityWoman typing on a Telecommunications Device for Deaf (TDD)Person with a disabilitySeeing eye dogAdult teaching a child how to read braille.  
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Date

Date of Birth  

Name

Age

Address County
Street

City/State/Zip
Phone #

Male         Female

Email Marital Status
Education
Disability  Yes No
Referred By (if applicable) If Yes, Please Identify
   
Employment Ethnicity Living Arrangement
Unknown Unknown Unknown
Never White (non Hispanic) Independent
Not Working / Have Black (non Hispanic)      (Single or with Others)
Working Part Time American Indian, Dependent
Working Full Time       Alaskan Native or      (with Family or Friends)
Retired       Hawaiian Assisted Living
Supported Asian / Pacific 
     Islander		 Institution
Other Hispanic Other
Declined
   
Interested in Volunteering   Yes     No
Information Requested or Comments


ROADS To Freedom CILNCP
24 East 3rd Street
Williamsport PA 17701 - 6633 
Ph: (570) 327-9070 
Toll Free: 1-(800) 984-7492
Fax: (570) 327-8610 
TTY: (570) 327-5254
Toll Free TTY 866-842-5426


  
© 2000 Center for Independent Living of North Central PA (CILNCP)® All rights reserved.